PEMERINTAH KOTA BOGOR

RUMAH SAKIT UMUM DAERAH No. RM : ..........................................

KOTA BOGOR
Jalan Dr. Sumeru No.120 Bogor, 16111
Nama : ...................................(L/P)
Telp.0251-8312292, Fax 0251-8371001 Tanggal Lahir : .........................................
ASESMEN AWAL MEDIS
RAWAT INAP DAN INTENSIF
(Dilengkapi dalam 24 jam pertama pasien masuk ruang rawat) (Mohon diisi atau tempelkan stiker jika ada)

Tiba di ruang : ................................. Tanggal ........................... Pkl.................

Pengkajian: Tanggal ........................... Pkl.................
Petunjuk pengisian : Beri tanda ( √ ) pada kolom yang dianggap sesuai

I. Anamnesis
1. Keluhan Utama (lama, pencetus)
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2. Riwayat penyakit sekarang
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3. Riwayat Penyakit Dahulu (termasuk riwayat operasi)
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4. Riwayat Penyakit Keluarga : Tidak ada Ada, sebutkan..................................................................
5. Riwayat Pekerjaan : Apakah pekerjaan pasien berhubungan dengan zat-zat berhaya (misalnya : Kimia, Gas,
Radiasi, dll) Tidak ada Ya, sebutkan .............................................................................................
6. Riwayat Alergi : Tidak Ada Ada, yaitu : Makanan : .........................................................................
Obat : .........................................................................
Lain-lain : ..........................................................................
Reaksi berupa : ..................................................................
7. Riwayat Penggunaan obat/herbal/jamu sebelum ke RS : Tidak ada Ada, sebutkan.............................
............................................................................................................. lanjut rekonsiliasi oleh farmasi klinik

II. Pemeriksaan Fisik

1. Keadaan Umum : Tampak tidak sakit Sakit ringan Sakit sedang Sakit berat
2. Kesadaran : Kompos mentis Apatis Somnolen Sopor Coma Coma
3. GCS : E................ M................ V.........................
4. Tanda Vital : TD ................ mmHg, Suhu : .............° C, RR :...........x/menit Nadi : ...............x/menit
5. Pemeriksaan : Status generalis dan status lokalis (Inspeksi, palpasi, perkusi dan auskultasi)
A. KEPALA :
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B. LEHER :
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C. DADA:
Jantung :
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Paru : ........................................................................................................................................................
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Terima kasih atas kerja samanya telah mengisi formulir ini dengan benar dan jelas FORM/RM-RANAP/010 – ReV00/2020 1/2
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D. ABDOMEN :
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E. PUNGGUNG :
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F. EKSTREMITAS :
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H. GENITALIA :
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III. Pemeriksaan Penunjang (Laboratorium, Radiologi, EKG, USG, dll)
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IV. Diagnosis Kerja
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.........Diagnosis Banding
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V. Perencanaan Pelayanan / Penatalaksanaan / Pengobatan :
(Terapi, tindakan, konsultasi, pemeriksaan penunjang lanjutan, edukasi, dsb)

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Rencana pulang : ................................................................. hari / tidak dapat diprediksi

Diisi oleh Dokter yang melakukan Tanda tangan Dokter DPJP

pemeriksaan/pengkajian
Tanggal :

Waktu selesai/pukul : Nama :

Terima kasih atas kerja samanya telah mengisi formulir ini dengan benar dan jelas FORM/RM-RANAP/010 – ReV00/2020 2/2